Proposed Rules Would Help States Evaluate Medicaid Beneficiary Access To Care

May 3

Last Friday (April 29th), the U.S. Department of Health & Human Services (HHS) released a proposed regulation that sets out a process for States to define what is otherwise ambiguous in the law: what it means to provide people on Medicaid with access to health care.

The law says that people with Medicaid must have generally the same access to care as people with other types of health insurance. And the research shows that people covered by Medicaid—mostly children, people with disabilities, the elderly and pregnant women — generally have good access to care.

But HHS has never issued formal rules to provide States with guidance on how to implement this portion of the law and that left States with many questions. And because those questions haven’t been resolved, some states have wound up in court and some judges have been forced to make Medicaid policy.

States, understandably, have asked for federal guidance on this question so experts and state leaders — not judges – can make decisions about their Medicaid programs.

The proposed regulation responds to State requests by suggesting a process and a framework for analysis, rather than imposing a rigid nationwide standard. States would be expected to review whether access is sufficient for the services they cover, looking at each service category (e.g., hospitals, physicians) once every five years, using a transparent process that solicits public input. In addition, States would need to consider access when they propose a provider payment rate reduction.

This process relies on the three-part framework developed by the Medicaid and CHIP Payment and Access Commission (MACPAC), which was created by Congress to look at these very issues. MACPAC suggests that access can best be evaluated by looking at enrollee needs, provider availability, and changes in the use of services.

Beyond this framework, we have proposed to leave it to States to determine which metrics are appropriate to consider. Every State is unique in terms of its delivery system, its enrollee needs and other key factors. A one-size fits all approach isn’t appropriate, and it isn’t something we have proposed.

We know that people will have different views about this proposal and we welcome all comments and opinions. This proposal is just that – a proposal for consideration – and nothing will go into effect until we have gathered and reviewed comments, made adjustments or modifications as appropriate, and issued a final rule.

These are difficult, complex questions and we look forward to hearing suggestions on additions, deletions, modifications, and different approaches. Let us know what you think.